Perspective

On Cancer: Memorial Sloan Kettering Experts Maintain That PSA Screening for Prostate Cancer Saves Lives

By Memorial Sloan Kettering  |  Friday, June 1, 2012
Pictured: Howard Scher Howard I. Scher, Chief of the Genitourinary Oncology Service

Last week, the US Preventive Services Task Force (USPSTF) released new recommendations that men no longer undergo blood tests to measure levels of prostate-specific antigen (PSA), a protein produced by the prostate gland. These recommendations contradict the prostate cancer screening guidelines developed by Memorial Sloan Kettering experts, which have been in place for about three years.

“We remain committed to our guidelines, which are based on years of careful studies and extensive review by our Medical Board,” says Howard I. Scher, Chief of the Genitourinary Oncology Service in Memorial Sloan Kettering’s Department of Medicine.

The USPSTF concluded that there is “moderate or high certainty” that prostate cancer screening as currently conducted in the United States has no net benefit or that the harms resulting from screening outweigh the benefits. The group based its analysis on data that weighed the risks and benefits of conducting PSA tests and digital rectal exams on an annual basis starting at age 50 – or at age 45 for men at higher risk – which is the current practice of many physicians. The risks cited are due in large part to false-positive tests that result in unnecessary procedures and to treatment for cancers that are unlikely to become life-threatening.

“There is no doubt that prostate cancer screening can be associated with harm, mainly the risk of diagnosis and treatment of cancers that pose little risk to life or health, while the treatment carries immediate risks of harm to normal body functions,” Dr. Scher says. “But the answer is not to stop screening altogether; it’s to do so more intelligently.”

Memorial Sloan Kettering experts concur with the recommendations against current screening practices in the United States. But they believe that the USPSTF has oversimplified the matter and did not take into account a more-selective and targeted approach to screening and treatment based on the assessment of the risk of having a clinically significant prostate cancer for each individual.

Evidence of the Benefits of Screening

Clinical trials have demonstrated that screening with PSA can reduce the risk of prostate cancer death by 20 to 44 percent over ten to 14 years when compared with not screening. Men who stand to benefit the most from early detection are those who are at high risk of dying from prostate cancer, including men with a family history of the disease, men with a genetic predisposition to prostate cancer, and African American men.

In addition to these risk factors, research carried out by Memorial Sloan Kettering investigators has shown that a man’s PSA level between the ages of 45 and 60 is the most powerful predictor of his lifetime risk of developing a life-threatening prostate cancer or dying from the disease.

Rather than a uniform screening approach for the whole population, Memorial Sloan Kettering guidelines recommend that men have an initial PSA test in their 40s, and that those at low-risk have testing less frequently, whereas men at intermediate to high risk have more frequent evaluations.

“Using this approach, the harms associated with overtreatment of low-risk cancer can be significantly or dramatically reduced by using an approach known as ‘active surveillance,’ or watchful waiting, which involves no immediate treatment but careful monitoring for changes in the cancer that show it has become more aggressive,” Dr. Scher says. “Definitive treatment of the prostate is only considered if it becomes measurably more threatening. We recommend that men found to have low-risk cancers strongly consider active surveillance rather than immediate therapy.”

“The mortality rate from prostate cancer in this country has declined steadily over the past 20 years with the widespread use of PSA testing,” Dr. Scher adds, “and the incidence of the disease and the mortality rate is likely to rise if testing substantially decreases.”

Comments

It is irresponsible of the USPSTF to say that there is no "benefit" of conducting PSA tests before the age of 50. I could be dead now if not for the test which uncovered a problem when I was 38. I am now 4 years Cancer free.

My brother was 50 when his first psa was elevated. A total prostatectomy saved his life. He is now 75, His son at 50 had an elevated psa. After many test he had a total prostatectomy. He is doing fine. Is it cost that is being condidered?

I doubt if any of the experts who produced the USPSTF recommendation ever had metastatic bone cancer that developed from prostate cancer that went too long without detection. I am ten years past radiation. Whether it was necessary or not, I am still alive. I have a question. When someone dies of metastatic bone cancer, is that considered a death from prostate or bone cancer for the statistics?

If the death results from prostate cancer that has spread to the bone, then the cause of death is metastatic prostate cancer (not bone cancer).

Thank you for remaining true to your own MSK guidelines!

I am in Better Staging now, now Thanks to Dr. James Eastham and Team. They Caught my PC with PSA Testing just as it was invading the Capsule to Breakout. Had a Radical Prostectomy.
Removed what appears to be all the PC....

My father was diagnosed ten+ years ago via screening procedures and is still alive getting hormone therapy at MSK. His father and his father's father died from the same thing. My oldest brother (I have 3 brothers) also was detected with prostate cancer and he had his removed in time. The screening DEFINITELY helps save lives!!!

I totally agree with Dr. Scher. I do, however, understand the USPSTF point of view as it relates to the issue of too many physicians not using the information from the PSA to rationally strategize the care of any man diagnosed with PC. But to advise against PSA testing because the "messengers" need better advice and to discard the valuable information that PSA and all of its derivative tests such as free PSA percentage, PSA density, PSA velocity and doubling time, PSA slope have given to us is a backwards intellectual move of grave importance. This is truly an issue of confusing the message with the messenger(s). Moreover, a diagnosis of PC does not mandate an invasive treatment strategy; the important take home lesson for any illness is for the physician-patient-family team to understand the need to "listen to the biology" and what it tells us. Lastly, the PSA itself tells an alert physician a lot about prostate health, be it BPH, prostatitis, PC or if a healthy prostate gland is present. A knowledgeable physician can step in depending on the results of PSA and derivative testing and alter the course of many maladies associated with any of the prostate conditions mentioned above. This is the essence of integrative medicine and of prevention.

If not PSA tests to identify prostate cancer, then what?

I can see where USPSTF's statements may have some validity in my own situation. Based on elevated PSA levels I had a prostate biopsy that found first stage cancer cells. I wanted to have my prostate removed but my urologist in combination with a second opinion convinced me that active survelliance was the proper course of action. Six years later my PSA levels and a subsequent biopsy show no advance with the cancer cells. If my doctor had not convinced me of this treatment a radical procedure such as prostate removal and all its related side effects could have considerably reduced my quality of life. PSA testing is important but the results must be interpreted by considerate, intelligent and open-minded doctors who can fully understand the consequences of their advice.

The USPSTF made a well reasoned economic recommendation and then failed to state it was not a medical recommendation. But for the PSA and its interpretation by Drs. Eastham and Zelefsky, my daughters' father, i.e. me, would not be alive to send this reply!!

I had a routine blood test at age 52, my general practioner died of old age and the new doctor suggested the blood test. My PSA numbers came back elevated and the new doctor suggested seeing a urologist. Well one thing lead to another and I could not believe my ears when the urologist told me I had Prostate Cancer. Seeking a second opinion I elected to go see the Doctors at Sloan Kettering, it's a good thing I did as my cncer was about to break through the walls and into the bones. Thank God I'm still here 7 years later to talk about it, Thanks to the doctors at Sloan Kettering and my new general practioner.

Yes it did save my life for almost last 17 years. At the time when I was diagnosed with Prostate Cancer my PSA was 1700 (ng/ml) stage 4. PSA was done on my request, though for years of rectal exams by doctors failed to detect any abnormality. I was then then told a survival chance of three months.
Now I am put on Zytiga (after Taxoter failed) and facing another challange as my desease is no longer controlled any more. One doctor wants to treat me with combined medications (Taxoter + Zytiga). The second doctor refuses to do so.
Please, can you tell me if it is a good approach to combine the two medications as mentioned above. Or can you combine Zytiga with Alpharadin? Is there any thing else can be done.
Can anyone advise me (sabery@videotron.ca). I am so confused.
Thanks

We are unable to answer specific medical questions on our blog. If you would like to make an appointment with a Memorial Sloan-Kettering physician, please call our Physician Referral Service at 800-525-2225. Thanks for your comment!

G M. I have had Esophagel cancer in 2002,, removed the esophagus completely...at Cornell by Dr Jeffery Port.doing ok so far... My PSA levels went as high as 7.2 in the past year.. been rising in the past three years. Finger test ,doctor states never felt a larger prostate.. put me on Flow max ..hoping for a drop in my level. Biopsy set for August 1st with . V A hospital...alot pain when urinating..,Cancer or not what are the effects of removal of prostate.. i am 59 years old .. lost my brother to lung cancer 2 yrs ago and dad to stomach cancer. I am lucky to still be here but i want to stay here ... Thank you God Bless

We are unable to answer specific medical questions on our blog. If you would like to make an appointment with a Memorial Sloan-Kettering physician, please call our Physician Referral Service at 800-525-2225. Thanks for your comment!

74 in great physical shape with no prior symptoms & complete surprise of Gleason 8, Radical?

I understand the USPSTF's perspective that PSA screening may offer no "net" benefit. The problem with their view is that it is an aggregate perspective but they are ignoring that cancer is individual.

In 1995 I was under the age of 50 and the physician who did my annual physical suggested testing my PSA so we could establish a baseline for future comarison. Turned out my PSA was 36. I had surgery and the cancer had started to spread outside the shell.

There is no family history of prostate cancer or any cancer for that matter. If that doctor had waited until I reached age 50 I would likely be dead now. So the USPSTF may belive there is no net benefit but I know there is an indivudal benefit and I am thankful that my physician didn't follow guidelines and dealt with me as an individual.

To Stephen Brennan on blog posted 7/3/2012:

When you say "the cancer had started to spread outside the shell...", what imaging procedure revealed that so you or your radiologist was able to tell that?

Thanks,
Hong

A Physicist

Though not mentioned in all previous posts, why is MRI-S not being talked about and utilized at a higher frequency for the non invasive detection of PC, as opposed to the more radical needle biopsy procedure? in my case, at 55 years old and not in any perceived high risk categories, my PSA has been screened yearly for the last 5 years with slight increases each year but no abnormal DRE results each time. my most recent PSA was read to increase to 4.3 from 3.7 last year, triggering a visit to a urologist and advised to have a needle biopsy. Is this screening result enough to warrant radical procedures for PC detection? known complications from needle biopsy can be enough to deter me from following this course, so i am considering MRI-S as the next step. if PC is found at any level, of course i will have to consider the various treatment options as warranted, but if not, I at least should learn my total prostate health at a very high level and without the possible drastic side affects of needle biopsy. Reading all this data and dialogue on screening vs non screening is confusing me to the point of both major anxiety and indecision, especially by all here who are "experts" in this field. thanks in advance for your comments.

We are unable to answer specific medical questions on our blog. If you would like to make an appointment with a Memorial Sloan-Kettering physician, please call our Physician Referral Service at 800-525-2225. Thanks for your comment!

I was 54 when a rising PSA (6.9) led to a urologist consult and biopsy, which showed prostate cancer at a Gleason 7, even though there were no palpable nodules on DRE in prior doctor visits. I had the radical surgery as a result, with post-op pathology coming in with a final Gleason 9 score, and extra-capsular extension with perineural invasion. Post-op PSA was undetectable, but I was put on Casodex for 1 year due to high recurrence risk. About 7 years later, PSA began to rise, had 39 tomotherapy sessions, and PSA did not go down. Consulted my urologist again, and he ordered a PET/CT which showed a lung nodule, and a VATS biopsy was converted to open thoracotomy and left upper lung lobectomy. Lymph node involvement was also noted at Level 11 during dissection. All this with a PSA of 1.9! I have been on Lupron for over a year, and while there is no denying the side effects, my PSA is still undetectable, and I am still very much alive and kicking. If I had not had the original PSA testing, despite no family history or overt symptoms, and which noted a rise after being stable for years, I would probably be a long time in the ground by now. I am now 64, and take each day as it comes, but they keep on coming, and I hope they do for a long time to come.

Does your information conclude that men 60-70 years of age with rising PSA velocities, with PSAs still within normal guidelines, and with negative DREs, should generally use "watchful waiting" rather than immediate biopsy as tx?

Thanks for your comment. This is from Peter Scardino, a prostate cancer expert who is Chair of our Department of Surgery: We recommend performing a biopsy on the basis of a man's PSA rather than the velocity. The guidelines say "consider biopsy" if the PSA is 3 or more. If you have any doubts, see your doctor for a more detailed discussion.

Please tell me the difference between a random biopsy and a targeted biopsy.

Dear Ron, thanks for your question. We suggest you contact the National Cancer Institute for an explanation of the difference. They are available to answer your questions at 1-800-4-CANCER (1-800-422-6237), Monday through Friday, 8:00 a.m. to 8:00 p.m. ET.

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